REGULATIONS
Vol. 37 Iss. 13 - February 15, 2021

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING
BOARD OF MEDICINE
Chapter 20
Forms

REGISTRAR'S NOTICE: Forms used in administering the regulation have been filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, 900 East Main Street, 11th Floor, Richmond, Virginia 23219.

Title of Regulation: 18VAC85-20. Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic.

Effective Date: February 15, 2021.

Agency Contact: Elaine J. Yeatts, Agency Regulatory Coordinator, Board of Medicine, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4688, or email elaine.yeatts@dhp.virginia.gov

Summary of Public Comments and Agency's Response: No public comments were received by the promulgating agency.

FORMS (18VAC85-20)

Instructions and Application for a License to Practice Medicine and Surgery in Virginia for Graduates of American Medical Schools (US/Canada) (rev. 3/10).

Instructions and Application for a License to Practice Medicine and Surgery for Graduates of Non-American Medical Schools (outside of the US/Canada) (rev. 3/10).

Information and Chiropractic Endorsement Application (rev. 12/08).

Information and Podiatry Endorsement Application (rev. 12/08).

Instructions and Application for a License to Practice Osteopathic Medicine (rev. 1/09).

Form A, Claims History Sheet (rev. 8/07).

Form B, Activity Questionnaire (rev. 10/09).

Form C, Clearance from Other State Boards (rev. 11/09).

Form E, Disciplinary Inquiry (rev. 5/11).

Form H, Federation of Podiatric Medical Boards Report (rev. 12/08).

Instructions and Application for a Temporary License for Intern/Resident Training Program (rev. 8/07).

Form A, Intern/Resident, Memorandum from Associate Dean of Graduate Medical Education (rev. 8/07).

Application to Practice Medicine, Osteopathic Medicine, Chiropractic, and Podiatry, online application available at https://www.license.dhp.virginia.gov/apply/

Application to Practice Medicine, by endorsement, online application at https://www.license.dhp.virginia.gov/apply/

Instructions for Completing an Application to Practice Medicine in Virginia for Graduates of Allopathic Medical Schools and Osteopathic Medical Schools (rev. 12/2017)

Instructions for Completing an Application to Practice Chiropractic in Virginia (rev. 12/2017)

Instructions for Completing an Application for Licensure by Endorsement (rev. 8/2020)

Instructions for Completing Podiatric Medicine Application (rev. 12/2017)

Form B, Activity Questionnaire (rev. 7/2017)

Form A, Intern/Resident, Memorandum from Associate Dean of Graduate Medical Education or Program Director (rev. 8/2007)

Form B, Intern/Resident Certificate of Professional Education (rev. 8/2007)

Form G, Intern Resident, Request for Status Report of ECFMG Certification (eff. 8/07)

Form H, Report of Clinical Rotations (rev. 12/02).

Transfer Request, Intern/Resident (eff. 8/07).

Intern/Resident, Transfer Request (rev. 6/2016)

Instructions for Completing an Application for a Limited License to Foreign Medical Graduates Pursuant to 54.1-2936 (rev. 8/2007)

Application for a Limited License to Foreign Medical Graduates Pursuant to 54.1-2936 (rev. 8/2007)

Form L, Certificate of Professional Education (rev. 12/08).

Instructions for Reinstatement of Medicine and Surgery Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice Medicine (rev. 3/09).

Form A, MD Reinstatement, Claims History Sheet (rev. 9/2009)

Form B, MD Reinstatement, Activity Questionnaire Form (rev. 8/07).

Form C, MD Reinstatement, State Questionnaire Form (rev. 8/07).

MD Reinstatement, Disciplinary Inquiries to Federation of State Medical Boards (rev. 8/07).

Instructions for Reinstatement of Osteopathic Medicine Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice Osteopathic Medicine (rev. 8/07).

Form A, Osteopathy Reinstatement, Claims History (rev. 8/07).

Instructions for Reinstatement of a Chiropractic Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice as a Chiropractor (rev. 8/07).

Instructions for Reinstatement of Podiatry Licensure Application (rev. 4/08).

Application for Reinstatement of License to Practice Podiatry (rev. 8/07).

Reinstatement Application Instructions for Medicine & Surgery or Osteopathy Licensure after Reinstatement Denied or License Revoked (rev. 8/07).

Reinstatement Application Instructions for Medicine & Surgery or Osteopathy Licensure after Mandatory Suspension, Suspension or Surrender (rev. 8/07).

Reinstatement Application Instructions for Podiatry Licensure after Mandatory Suspension, Suspension or Surrender (rev. 8/07).

Application for Reinstatement of License to Practice Medicine/Osteopathy After Petition for Reinstatement Denied or License Revoked (rev. 8/07).

Application for Registration for Volunteer Practice (rev. 8/07).

Sponsor Certification for Volunteer Registration (rev. 8/08).

Guidelines for Completing the Practitioner Profile Questionnaire (rev. 7/11).

Practitioner's Help Section (rev. 11/10).

Practitioner Questionnaire (rev. 7/11).

Reinstatement of a Podiatry License – Please contact Pam Smith for licensure package at (804) 367-4570 or pam.smith@dhp.virginia.gov

MD/DO Reinstatement Instructions and Application for MD and DO licenses in EXPIRED status for more than two years ONLY (rev. 8/2020)

Instructions for Reinstatement of a Chiropractic Licensure Application (rev. 4/2018)

Application for Registration for Volunteer Practice (rev. 8/2015)

Sponsor Certification for Volunteer Registration (rev. 3/2018)

Application for Restricted Volunteer License (rev. 12/2007)

VA.R. Doc. No. R21-6639; Filed January 24, 2021